White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch

Facility

$45,362.28

Service Code	HCPCS 92924
Hospital Charge Code	994088
Hospital Revenue Code	481
Min. Negotiated Rate	$747.34
Max. Negotiated Rate	$32,660.84
Rate for Payer: Amerigroup CHIP/Medicaid	$4,082.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Amerigroup Medicare	$11,596.79
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$11,596.79
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$30,846.35
Rate for Payer: Cash Price	$30,846.35
Rate for Payer: Cash Price	$30,846.35
Rate for Payer: Cigna Commercial	$24,513.51
Rate for Payer: Cigna Medicaid	$32,660.84
Rate for Payer: Cigna Medicare	$11,596.79
Rate for Payer: Employer Direct Commercial	$11,596.79
Rate for Payer: Humana Medicare/TRICARE	$11,596.79
Rate for Payer: Molina CHIP/Medicaid	$32,660.84
Rate for Payer: Molina Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Molina Medicare	$11,596.79
Rate for Payer: Multiplan Auto	$29,485.48
Rate for Payer: Multiplan Commercial	$29,485.48
Rate for Payer: Multiplan Workers Comp	$29,485.48
Rate for Payer: Parkland Medicaid	$32,660.84
Rate for Payer: Scott and White EPO/PPO	$747.34
Rate for Payer: Scott and White Medicare	$11,596.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32,660.84
Rate for Payer: Superior Health Plan EPO	$11,596.79
Rate for Payer: Superior Health Plan Medicare	$11,596.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,596.79
Rate for Payer: Universal American Medicare	$11,596.79
Rate for Payer: Wellcare Medicare	$11,596.79
Rate for Payer: Wellmed Medicare	$11,596.79

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy

Facility

$18,794.85

Service Code	HCPCS 22513
Hospital Charge Code	9900203
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,780.50

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy

Facility

$50,119.60

Service Code	HCPCS 22514
Hospital Charge Code	9900204
Hospital Revenue Code	360
Rate for Payer: Cash Price	$34,081.33

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy

Facility

$18,794.85

Service Code	HCPCS 22513
Hospital Charge Code	9900203
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$13,532.29
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$13,532.29
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$13,532.29
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,532.29
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy

Facility

$15,408.22

Service Code	CPT 22514
Hospital Charge Code	36022514
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy

Facility

$15,408.22

Service Code	CPT 22513
Hospital Charge Code	36022513
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy

Facility

$50,119.60

Service Code	HCPCS 22514
Hospital Charge Code	9900204
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$36,086.11
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$34,081.33
Rate for Payer: Cash Price	$34,081.33
Rate for Payer: Cash Price	$34,081.33
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$36,086.11
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$36,086.11
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$36,086.11
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36,086.11
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy i

Facility

$37,589.70

Service Code	HCPCS 22514
Hospital Charge Code	9900205
Hospital Revenue Code	360
Rate for Payer: Cash Price	$25,561.00

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy i

Facility

$37,589.70

Service Code	HCPCS 22514
Hospital Charge Code	9900205
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$27,064.58
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$25,561.00
Rate for Payer: Cash Price	$25,561.00
Rate for Payer: Cash Price	$25,561.00
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$27,064.58
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$27,064.58
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$27,064.58
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,064.58
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy i

Facility

$10,000.00

Service Code	CPT 22515
Hospital Charge Code	36022515
Hospital Revenue Code	360
Min. Negotiated Rate	$262.25
Max. Negotiated Rate	$10,000.00
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$262.25

PER CUT CORO ANGIOPLASTY EA ADD ART

Facility

$3,621.00

Service Code	HCPCS 92921
Hospital Charge Code	2350031
Hospital Revenue Code	481
Rate for Payer: Cash Price	$2,462.28

PER CUT CORO ANGIOPLASTY EA ADD ART

Facility

$3,621.00

Service Code	HCPCS 92921
Hospital Charge Code	2350031
Hospital Revenue Code	481
Min. Negotiated Rate	$325.89
Max. Negotiated Rate	$2,607.12
Rate for Payer: Amerigroup CHIP/Medicaid	$325.89
Rate for Payer: BCBS of TX Blue Advantage	$1,086.30
Rate for Payer: BCBS of TX Blue Essentials	$1,303.56
Rate for Payer: BCBS of TX PPO	$1,448.40
Rate for Payer: Cash Price	$2,462.28
Rate for Payer: Cigna Medicaid	$2,607.12
Rate for Payer: Molina CHIP/Medicaid	$2,607.12
Rate for Payer: Multiplan Auto	$2,353.65
Rate for Payer: Multiplan Commercial	$2,353.65
Rate for Payer: Multiplan Workers Comp	$2,353.65
Rate for Payer: Parkland Medicaid	$2,607.12
Rate for Payer: Scott and White EPO/PPO	$1,810.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,607.12
Rate for Payer: Superior Health Plan EPO	$492.46

PER CUT CORONRY ANGIOPLASTY 1ST ART

Facility

$8,180.00

Service Code	HCPCS 92920
Hospital Charge Code	2350030
Hospital Revenue Code	481
Min. Negotiated Rate	$626.55
Max. Negotiated Rate	$12,483.85
Rate for Payer: Amerigroup CHIP/Medicaid	$736.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Amerigroup Medicare	$5,717.50
Rate for Payer: BCBS of TX Blue Advantage	$8,273.03
Rate for Payer: BCBS of TX Blue Essentials	$9,907.82
Rate for Payer: BCBS of TX Medicare	$5,717.50
Rate for Payer: BCBS of TX PPO	$12,483.85
Rate for Payer: Cash Price	$5,562.40
Rate for Payer: Cash Price	$5,562.40
Rate for Payer: Cash Price	$5,562.40
Rate for Payer: Cigna Commercial	$12,085.75
Rate for Payer: Cigna Medicaid	$5,889.60
Rate for Payer: Cigna Medicare	$5,717.50
Rate for Payer: Employer Direct Commercial	$5,717.50
Rate for Payer: Humana Medicare/TRICARE	$5,717.50
Rate for Payer: Molina CHIP/Medicaid	$5,889.60
Rate for Payer: Molina Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Molina Medicare	$5,717.50
Rate for Payer: Multiplan Auto	$5,317.00
Rate for Payer: Multiplan Commercial	$5,317.00
Rate for Payer: Multiplan Workers Comp	$5,317.00
Rate for Payer: Parkland Medicaid	$5,889.60
Rate for Payer: Scott and White EPO/PPO	$626.55
Rate for Payer: Scott and White Medicare	$5,717.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,889.60
Rate for Payer: Superior Health Plan EPO	$5,717.50
Rate for Payer: Superior Health Plan Medicare	$5,717.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,717.50
Rate for Payer: Universal American Medicare	$5,717.50
Rate for Payer: Wellcare Medicare	$5,717.50
Rate for Payer: Wellmed Medicare	$5,717.50

PER CUT CORONRY ANGIOPLASTY 1ST ART

Facility

$8,180.00

Service Code	HCPCS 92920
Hospital Charge Code	2350030
Hospital Revenue Code	481
Rate for Payer: Cash Price	$5,562.40

PERC VERT 1 BD ADD/IMG

Facility

$885.00

Service Code	HCPCS 22512
Hospital Charge Code	4614480
Hospital Revenue Code	361
Rate for Payer: Cash Price	$601.80

PERC VERT 1 BD ADD/IMG

Facility

$885.00

Service Code	HCPCS 22512
Hospital Charge Code	4614480
Hospital Revenue Code	361
Min. Negotiated Rate	$79.65
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$79.65
Rate for Payer: BCBS of TX Blue Advantage	$265.50
Rate for Payer: BCBS of TX Blue Essentials	$318.60
Rate for Payer: BCBS of TX PPO	$354.00
Rate for Payer: Cash Price	$601.80
Rate for Payer: Cash Price	$601.80
Rate for Payer: Cigna Medicaid	$637.20
Rate for Payer: Molina CHIP/Medicaid	$637.20
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$637.20
Rate for Payer: Scott and White EPO/PPO	$442.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$637.20
Rate for Payer: Superior Health Plan EPO	$120.36

PERC VERT 1BD CTHOR/IMG

Facility

$1,479.00

Service Code	HCPCS 22510
Hospital Charge Code	4614478
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,005.72

PERC VERT 1BD CTHOR/IMG

Facility

$1,479.00

Service Code	HCPCS 22510
Hospital Charge Code	4614478
Hospital Revenue Code	361
Min. Negotiated Rate	$1,064.88
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$1,005.72
Rate for Payer: Cash Price	$1,005.72
Rate for Payer: Cash Price	$1,005.72
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$1,064.88
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$1,064.88
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,064.88
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,064.88
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

PERC VERT 1 BD LSAC/IMG

Facility

$1,479.00

Service Code	HCPCS 22511
Hospital Charge Code	4614479
Hospital Revenue Code	361
Min. Negotiated Rate	$1,064.88
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$1,005.72
Rate for Payer: Cash Price	$1,005.72
Rate for Payer: Cash Price	$1,005.72
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$1,064.88
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$1,064.88
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,064.88
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,064.88
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

PERC VERT 1 BD LSAC/IMG

Facility

$1,479.00

Service Code	HCPCS 22511
Hospital Charge Code	4614479
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,005.72

PERFORATOR 14MM DISP

Facility

$1,375.62

Hospital Charge Code	992719
Hospital Revenue Code	272
Min. Negotiated Rate	$123.81
Max. Negotiated Rate	$990.45
Rate for Payer: Amerigroup CHIP/Medicaid	$123.81
Rate for Payer: BCBS of TX Blue Advantage	$412.69
Rate for Payer: BCBS of TX Blue Essentials	$495.22
Rate for Payer: BCBS of TX PPO	$550.25
Rate for Payer: Cash Price	$935.42
Rate for Payer: Cigna Medicaid	$990.45
Rate for Payer: Molina CHIP/Medicaid	$990.45
Rate for Payer: Multiplan Auto	$894.15
Rate for Payer: Multiplan Commercial	$894.15
Rate for Payer: Multiplan Workers Comp	$894.15
Rate for Payer: Parkland Medicaid	$990.45
Rate for Payer: Scott and White EPO/PPO	$687.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$990.45
Rate for Payer: Superior Health Plan EPO	$187.08

PERFORATOR 14MM DISP

Facility

$1,375.62

Hospital Charge Code	992719
Hospital Revenue Code	272
Rate for Payer: Cash Price	$935.42

PERICARDIOCENTESIS W/IMAGING WHEN PERFORMED

Facility

$3,059.00

Service Code	HCPCS 33016
Hospital Charge Code	4613010
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,080.12

PERICARDIOCENTESIS W/IMAGING WHEN PERFORMED

Facility

$3,059.00

Service Code	HCPCS 33016
Hospital Charge Code	4613010
Hospital Revenue Code	361
Min. Negotiated Rate	$446.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$446.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Amerigroup Medicare	$1,581.33
Rate for Payer: BCBS of TX Blue Advantage	$2,723.99
Rate for Payer: BCBS of TX Blue Essentials	$3,262.26
Rate for Payer: BCBS of TX Medicare	$1,581.33
Rate for Payer: BCBS of TX PPO	$4,110.45
Rate for Payer: Cash Price	$2,080.12
Rate for Payer: Cash Price	$2,080.12
Rate for Payer: Cash Price	$2,080.12
Rate for Payer: Cigna Commercial	$3,342.63
Rate for Payer: Cigna Medicaid	$2,202.48
Rate for Payer: Cigna Medicare	$1,581.33
Rate for Payer: Employer Direct Commercial	$1,581.33
Rate for Payer: Humana Medicare/TRICARE	$1,581.33
Rate for Payer: Molina CHIP/Medicaid	$2,202.48
Rate for Payer: Molina Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Molina Medicare	$1,581.33
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,202.48
Rate for Payer: Scott and White EPO/PPO	$2,709.66
Rate for Payer: Scott and White Medicare	$1,581.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,202.48
Rate for Payer: Superior Health Plan EPO	$1,581.33
Rate for Payer: Superior Health Plan Medicare	$1,581.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,581.33
Rate for Payer: Universal American Medicare	$1,581.33
Rate for Payer: Wellcare Medicare	$1,581.33
Rate for Payer: Wellmed Medicare	$1,581.33

PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM

Facility

$44,423.90

Service Code	MSDRG 041
Min. Negotiated Rate	$20,282.24
Max. Negotiated Rate	$44,423.90
Rate for Payer: BCBS of TX Blue Advantage	$20,282.24
Rate for Payer: BCBS of TX Blue Essentials	$24,336.33
Rate for Payer: BCBS of TX PPO	$27,041.41

Know your out-of-pocket cost for care.

All Charges